In Nigeria, more than 80 per cent of the about 52,000 women deaths recorded annually from child delivery or pregnancy-related complications is preventable yet a community exits in Lagos where pregnant women shun hospitals for antenatal care, ODIRI UCHENUNU-IBEH writes.
Shakitat Yakubu is 33 years old. She is a resident of Agboyi, a community in the Agboyi-Ketu Local Council Development Area (LCDA) in Kosofe Local Government of Lagos State.
Yakubu, a mother of three, is expecting her fourth child as she is eight months pregnant. But rather than attend one of the numerous Primary Health Care (PHC) Centres that dot the area for her antenatal, Yakubu patronises Mama Nurat, one of the Traditional Birth Attendants (TBAs) in the community.
She is, however, not alone; she is just behaving like other women in her community which is populated by not fewer than 40,000 people.
The community that comprises Agboyi 1, 2 and 3 is surrounded by water with no bridge to link it with neighbouring communities like Alapere and Ogudu. The only means of transportation are canoes which are very few.
The National Population Commission (NPC) puts maternal deaths in Nigeria at 52,000 cases annually while statistics by the United Nations Children’s Fund (UNICEF) show that a woman’s chance of dying from pregnancy and childbirth in Nigeria is one in 13.
This figure excludes the pregnant women residing in the rural areas, who do not go to hospitals for whatever reasons they deem. In addition, quite a number of women have been known to shun hospitals and rather patronise Traditional Birth Attendants (TBAs).
Such is the situation in Agboyi and Yakubu is one of the women.
LEADERSHIP Weekend visited the coastal community which only means of transportation to neighbouring communities are canoes.
It was, however, learnt that the LCDA has a functional Primary Healthcare Centre (PHC), offering maternal health services like prenatal, antenatal and counselling services, a large number of pregnant women still prefer the TBAs.
A chief nursing officer, who refuses to disclose her name (because she is not authorised to speak with the press) says most pregnant women patronise TBAs, adding that some of them (the women) only come around to take immunisation only to go back to TBAs for antenatal and delivery.
She says, “They seem to have a strong relationship with TBAs because they patronise them and some of the women use church maternity. The few that access ANC at the PHC usually make arrangement with someone that will carry them across the water to the PHC where they would deliver should they fall into labour at night.”
Since there is no road, good water, and the environment is dirty, the nurse advises that the government should provide these basic amenities and the people that will be taking care of them.
The health officer adds, “By the time we have all these in place, pregnant women won’t have problem coming for ANC and as for those who want to use the TBA, I advise that they still need to register with the PHC for prenatal and antenatal care.”
One of the reasons the pregnant women gave for patronising TBAs included the fact that the PHC doesn’t run for 24 hours, lacks adequate drugs, medical doctors and other quality services.
Ayo, a 33-year old woman did not hide the fact that she patronises TBAs. “I don’t have any problem at all delivering my baby at Mama Agoro Nurat’s place. I am eight months pregnant with my third child. I prefer her because she gives herbs and can detect if there are complications.”
Yakubu tells LEADERSHIP Weekend, “I am eight months pregnant and I had my three children in this TBA and God has been helping me as I have never had problem.”
When asked what Mama Nurat normally gives her, Yakubu replies, “I used to collect agbo and medicine from Mama Nurat; but I used to go to health centre to collect injection. I go to Mama Nurat every Monday for my antenatal, where she would test me and give me medicine depending on the issue I presented to her. When it was time for me to deliver, she did not collect so much money; she collected N5,000 only. I also brought along, the cloth my baby would wear, Dettol, spirit, cotton board and other baby things.”
As for Kukoyi Islamiat, who is also pregnant with her second child, she also patronises Mama Nurat.
She explains, “This place is good and as I don’t have any parent, she is like a mother to me. Some people do go to hospital whereas so many come here. Even if I have money I won’t go to the hospital because I am treated well here; so I don’t need a hospital.”
While the PHC doesn’t run for 24 hours, Mama Nurat, who has been practising for 25 years, says pregnant women can come to her place at any time of the day and they will be attended to.
When asked if she gives special treatment, the TBA answers: “There is no special treatment. It is just that there is no 24-hour hospital service here. That is why people prefer to register with me because I can attend to them even at midnight. Perhaps if there were a 24-hour PHC service in this vicinity, the situation would be better a little.”
In case of complications, Nurat says, “I have all the boat riders’ numbers and I call them at any time to come to my aid even if they have closed for the day. I also have the phone numbers of tricycles drivers who I normally beg to help me get boats. I use health centre for referral that is beyond my ability and if the case is beyond them, the health centre will refer the patient to Mascara or General Hospital, Gbagada.”
Speaking about her qualifications, she says, “I went to learn the work in a TBA at Bariga and I have attended programmes related to TBAs as well. I have taken delivery of several women whose children are already giving birth. Over 200 women have registered with me since 2016. I have a certificate from the Lagos State Board of Traditional Medicines and I do renew my licence every year.”
The Asoju-Oba of Agboyi-Ketu land, Chief Timothy Bankole, says women in the community patronise TBAs because their services are available day and night, adding that it has been an age-long tradition of pregnant women in the LCDA to access quality healthcare, especially when they are about to put to birth, because the PHC does not run for 24 hours.
As a retired civil servant, Bankole says he has appealed to the state government on behalf of the other Obas in the LCDA for a bridge to be constructed, so that people, especially pregnant women, can easily access the nearest flagship PHC centre.
“I believe the government is working assiduously on that. I also want to use this opportunity to appeal to the chairman of the local government to take the health sector seriously and make it his main focus because until we have 24-hour PHC here, there might not be much improvement in maternal health,” he added.
Meanwhile, stakeholders who spoke with LEADERSHIP Weekend said the fact that TBAs might not be responsible for the high maternal mortality rate in the country, even with Lagos State having a Maternal Mortality Ratio (MMR) of 650 per 100,000 live births, according to Nigerian Demographic and Health Survey (NDHS 2008).
They said Nigeria could avert or reduce maternal mortality by up to 80 per cent if the government creates more awareness on the importance of pregnant women accessing ANC early, adding that in that case, pregnant women would know the importance of ANC to their overall health and their unborn babies and, perhaps, stop patronising TBAs.
The World Health Organisation (WHO) says pregnancy-related deaths and diseases remain unacceptably high, adding that in 2015, an estimated 303 000 women died from pregnancy-related causes; 2.7 million babies died during the first 28 days of life and 2.6 million babies were stillborn.
While substantial progress has been made over the past two decades, WHO says increased access to, and use of, higher-quality health care during pregnancy and childbirth can prevent many of these deaths and diseases, as well as improve women and adolescent girls’ experience of pregnancy and childbirth.
The organisation says globally, only 64 per cent of women receive ANC four or more times throughout their pregnancy, adding that ANC is not for the assessments of mother and foetal only, but also include counselling on healthy diet and optimal nutrition, physical activity, tobacco and substance use; malaria and HIV prevention; blood tests and tetanus vaccination; foetal measurements including use of ultrasound; and advice for dealing with common physiological symptoms such as nausea, back pain and constipation.
Recently, WHO released a new guidance which increases the number of contacts a pregnant woman has with health providers throughout her pregnancy from four to eight, noting, recent evidence indicates that a higher frequency of antenatal contacts by women and adolescent girls with a health provider is associated with a reduced likelihood of stillbirths.
“This is because of the increased opportunities to detect and manage potential complications. Eight or more contacts for ANC can reduce perinatal deaths by up to eight per 1,000 births when compared to four visits.
“The new model increases maternal and foetal assessments to detect complications, improves communication between health providers and pregnant women, and increases the likelihood of positive pregnancy outcomes.
“It recommends pregnant women to have their first contact in the first 12 weeks’ gestation, with subsequent contacts taking place at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation,” added WHO.
Director of Maternal, Newborn, Child and Adolescent Health, WHO, Dr Anthony Costello, said, “More and better quality contacts between all women and their health providers throughout pregnancy will facilitate the uptake of preventive measures, timely detection of risks, reduces complications and addresses health inequalities, adding that ANC for first time mothers is key.”
As for the Director, Department of Nutrition for Health and Development, WHO, Dr Francesco Branca, “Counselling about healthy eating, optimal nutrition and what vitamins or minerals women should take during pregnancy can go a long way in helping them and their developing babies stay healthy throughout pregnancy and beyond.”
The Commissioner for Health, Lagos State, Dr. Jide Idris, in an interview with LEADERSHIP Weekend said all stakeholders in the health sector have an obligation to ensure that the right of every citizen to access affordable and equitable healthcare services irrespective of gender, culture or socio-economic status is attained.
Idris said a lot of the healthcare budget goes to hospital services. He said, “80 to 89 per cent of our budget is going to curative care while less than five per cent is going to preventive care.”
Idris, however, advocated that more power should be given to the people. He said, “Let us give the power to the people. It is our responsibility as leaders to empower the people. We need to enlighten them on the need to use the PHC.
“The government is doing a lot in the healthcare system. We are building hospitals, staffing them and bringing in new technologies; but one physical aspect of primary health care which is the only key is community engagement, which we tend to forget. When we build these facilities and the community doesn’t make use of it, it is pointless to build it in the first place.
“Also, health commercial and disease prevention are part and parcel of universal healthcare because healthcare must be comprehensive in that, you have to promote good healthcare practices, then prevention before coming to treatment which we tend to pay more attention to.”
Since about 80 per cent of the diseases plaguing mankind can be prevented, Idris urged the government to use the lean budget allocation to empower the people by sensitising them and ensuring that they make use of the facilities that the government has built for them.
He also appealed to the Civil Society Organisations (CSOs) to check the government and hold them accountable for the promises made.
The commissioner said, “It is recommended that major stakeholders in the health sector create an opportunity to remind the Federal Government (law makers inclusive) of its commitments; local or international, such as the Abuja Declaration.
“Let us do more on prevention and to do that, we need to sensitise our people, we need to empower them. The CSOs need to play a role also. They need to check the government and hold them accountable for the promises made; they need to fight for the people, by going to the house of assembly, and asking them to increase the budget to the health sector.”
The Director, Family Health and Nutrition, Lagos State Ministry of Health, Dr. Folashade Oludara, while addressing the issue of TBAs said, looking at the number of TBAs in the communities to have immunization, how important they are to community people, the state government went ahead to ensure that at least all registered TBAs must have a form of formal training to be able to identify danger signs in pregnancy and then to be able to identify when to refer, so that pregnant women will not be in danger which in return will avert the death of maternal and even the unborn children.
Oludara said, “Things that kill babies or deform them occur in the first one week of pregnancy. We are advocating that every pregnant woman should go through at least four ANC so that they can be given the necessary drugs that will not only help them but would also help to prevent their children from deadly diseases, and deformity, even though they want to patronize TBAs.”
The founder, Spina Bifida and Hydrocephalus Care Foundation of Nigeria, Comrade Olubunmi Lawal-Aiyedun, said deformities in children happen during the first 28 days of pregnancy, usually before a woman even knows she is pregnant and that is why it is important for all pregnant women to register for early antenatal care so that folic acid along with other essential drugs can be given to them to make them and their unborn babies healthy.”
Despite the importance of ANC, hundreds of thousands of women in this country, do not visit a hospital until they fall into labour, even then some do not go to hospitals.
For instance, a scorecard that the Lagos State Accountability Mechanism for Maternal and Newborn Health (LASAM) produced with support from MamaYe indicates poor performance in certain maternal and newborn health indicators, such as attendance of antenatal care, immunisation, contraception, and malaria treatment.
According to the scorecard, only about 32 per cent of the pregnant women in Ibeju-Lekki LGA registered for antenatal care before 20 weeks of pregnancy. The other 68 per cent may be receiving care from TBAs, faith base home or no care at all.
The implication of this is that more than a half of the pregnant women in that LGA are missing out on the opportunity to receive health messages and be assessed for risk factors and the correct care if problems are detected.
This puts them at greater risk of health problems, which could result in the worst case scenario.
LASAM, after producing its scorecard, encouraged the Lagos State Government to promote awareness on family planning, early registration for antenatal care (before 20 weeks of pregnancy), and full immunisation coverage for children under the age of one, amongst others.